Rehabil itation of the Individual with Osseointegration: Similarit ies and Differences to Conventional

Socket Technology

Miche l le J . Nords t rom, OTR/LLaura Fr iedman, PT, DPT

PresenterPresentation NotesThe focus today is to elaborate on the differences between rehabilitation for the standard socket prosthetic vs. rehabilitation for osseointegration

Disclaimer

The views expressed in this presentation are those of the author and do not reflect the

official policy of the Department of the Army, Department of the Navy, the

Department of Defense or the United States Government. The author has no conflict of

interest to disclose.

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PresenterPresentation NotesStandard disclaimer

Prosthesis Options and Opportunities

Socket• The essential point of

integration between human tissue and replacement limb.

• The socket distributes the stress during weight-bearing, suspension and ambulation

Osseointegration• Firm anchoring of a surgical

implant (as in dentistry or in bone surgery) the growth of bone around it without fibrous tissue formation at the interface. (Merriam-Webster)

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PresenterPresentation NotesAt this time we are touching on the basic facts that we have two different suspension systems available and many varieties to choose from within each of the attachment options.

Why Eliminate the Socket

TransfemoralSocket• Short residual limb• Suspension challenges• Limited ROM• Uncomfortable- sitting, brim• Hot, Perspiration• Donning- pull bag• Liners

TranshumeralSocket

• Limited ROM• Uncomfortable• Hot, Perspiration• Suspension• Donning- pull bag

Harnessing• Uncomfortable• Cumbersome• Irritate skin• Contralateral Nerve issues

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PresenterPresentation NotesWhy can’t we leave good enough alone? Not everyone will have challenges with their socket but many patients do.

Upper Limb Rehab Timeline: Conventional Prosthesis

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Post Amputation Surgery Week 0 Week 1 Week 2 Week 3 Week 4 Week 5 Week 6 Week 7 Week 8 Week 9 Week 10 Week 11 Week 12Wound Care daily or as needed

Compression wrapping 24 hours/dayActive ROM therex to all joints as directed

Proximal strengthening exercisesResistive upper body strengthening program(once medically stable and pain controlled)

Myosite trainingFit with liner

Axial weight loadingFit with full length prosthesis

PresenterPresentation NotesMyosite training – wait for a few weeks after myodesis - Not listed in CPG but it is the general procedure used at WRNMMC

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Post Amputation SurgeryWeek 0Week 1Week 2Week 3Week 4Week 5Week 6Week 7Week 8Week 9Week 10Week 11Week 12

Wound Care daily or as needed

Compression wrapping 24 hours/day

Active ROM therex to all joints as directed

Proximal strengthening exercises

Resistive upper body strengthening program

(once medically stable and pain controlled)

Myosite training

Fit with liner

Axial weight loading

Fit with full length prosthesis

Conventional Prosthesis Fitting

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Initial Amputation SurgeryWeek 0-6Remain NWB

Check Socket3-6 weeks post opOnce cleared my surgeon, casted and fit with plastic check socket

Full Length Preparatory Prosthesis3-6 weeks post opFit with full length preparatory prosthesis of any type: BP, myoelectric, hybrid, passive

Definitive prosthesisApprox. 6-12 weeks +Limb volume has stabilized, and fit of prosthesis maximized. Move to carbon fiber socket.

Liner Fitting3-6 weeks post opOnce sutures removed and skin is healed fit with custom liner

1 week in liner

PresenterPresentation NotesDonning a Socket based Prosthesis Pin Lock SuspensionMulti-step donning process:Roll on pin lock linerParachute for pull in methodHarness

May require multiple attempts for positioning and to get all the way into the socket

Functional Benefits vs Limitations of Conventional Prosthesis

Limitations• Restrictive harnessing• Socket suspension increases

risk of skin breakdown• Decreased range of motion• Reduced functional envelope

Benefits• Greater tolerance for axial

loading• Potential for greater excursion • Increased tolerance for

resistance therex

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PresenterPresentation Notes

Osseointegration at WRNMMC

Clinical Trials• Transdermal Compress™ For Transfemoral Amputations

– IDE Sponsor: Zimmer-Biomet– Multicenter: Univ. Utah, Pitt, Walter Reed, WVU, Univ. Colorado– Submit to FDA March 2017, Begin Enrollment Fall 2017

• Transhumeral Amputation Osseointegration Study (TAOS) – FDA Approved Early Feasibility Study using the OPRA device– IRB Approved on – Currently Enrolling at Walter Reed and UCSF

• Transfemoral Amputation Osseointegration Study (TFAOS)– FDA Approved (HDE) OPRA device– IRB approved – Currently Enrolling at Walter Reed

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Upper Limb Rehab Timeline: OPRA

TAOS Transhumeral Prosthetic Fitting (OPRA)

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Surgery 1 (S1)2-3 Weeks post S1Skin is healed -fit with conventional prosthesis (stay away from distal pressure in socket)

Surgery 2 (S2) 3-6 weeks post S2Fit with short weight training prosthesis . Ability to increase weight.

Post S2 12-16 weeks: Fit with full length, lightweight partial functioning prosthesis

Post S2Surgeons approvalWith Surgeon's Approval Full weight/functioning prosthesis

3 months

Functional Benefits vs Limitations of Osseointegration Prosthesis

Limitations• Infection• Loosening of the

fixture• Mechanical failure• Reduction in activities

which require increased stress on the abutment through:– Torque– Repetitive loading

Benefits• More natural feeling• Osseoperception• Freedom of movement• Comfort while seated• Ease of putting on and taking off the prosthesis• Increased control and balance• Edema no longer leads to poor socket fitting and instability• Reduced back pain• No skin breakdown

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Why is this so important?

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It’s the little things in life that matter most!

• Sitting comfortably around the house and in the car• Using both arms to carry / support items• Cooking – using both hands and good ergonomics• Writing

Transfemoral Prosthetic Fitting Schedule One Stage(Compress) Custom Device

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Transfemoral Rehabilitation Progression: Compress• Non-weight bearing x 8 weeks• 8 weeks post op & upon clearance from

surgeon; initiate weight bearing (WB) 25% of body weight with short training prosthesis

• Progress 25% WB increase each week thereafter with short training prosthesis

• Progress to gait training outside of // bars on even terrain

• Progress from even terrain to uneven terrain, different directions, slopes, over obstacles, etc.

• Sitstand transfers with->without assistive device

• Sit in chairs with different heights• Stair climbing

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Transfemoral Rehabilitation Progression: OPRA

• Between Stage 1 and Stage 2– Wound Care– ROM– Strength training

• Core conditioning • Strength training residual limb and intact limb

• After Stage 2– Wound Care– ROM restriction POD #1-5– WB tolerance with short training prosthesis between 4-6 weeks upon

clearance from surgeon– Overall strength and core conditioning

• Post op week 13-24– Progress to gait training outside of // bars on even terrain– Progress from even terrain to uneven terrain, different directions,

slopes, over obstacles, etc– Sitstand transfers with->without assistive device– Sit in chairs with different heights– Stair climbing

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Functional Benefits

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• Overall increase in independence• Osseoperception

– Increased control • Balance• Proprioception• Manipulation/ terrain changes

– Feels more comfortable and natural.• No longer an issue

– Suspension System– Edema– Skin breakdown

• Reduction in – Back and shoulder pain– Skin Breakdown

PresenterPresentation NotesIt took 1 min 30 seconds to fully assemble this M16 using COAPT pattern Recognition, Ottobock elbow and iLimb terminal device

Additional Considerations

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Factors that may predict success• Intact visual or sensory function• Proper nutrition• Good overall health and fitness• Positive mental outlook• Supportive family and friends

Factors that may interfere with success• Uncontrolled pain• Tobacco use• Marked sensory loss• Depression• Absence of family support

Factors to consider with OI rehab• Level of independence after procedure • Amount of assistance available during time of

rehabilitation• Psychosocial impact• Economical impact

Questions

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Slide Number 1Disclaimer Prosthesis Options and OpportunitiesWhy Eliminate the SocketUpper Limb Rehab Timeline: Conventional ProsthesisConventional Prosthesis FittingFunctional Benefits vs Limitations of �Conventional ProsthesisOsseointegration at WRNMMCSlide Number 9TAOS Transhumeral Prosthetic Fitting (OPRA)Functional Benefits vs Limitations of Osseointegration ProsthesisWhy is this so important?It’s the little things in life that matter most!Transfemoral Prosthetic Fitting Schedule One Stage�(Compress) Custom DeviceTransfemoral Rehabilitation Progression: CompressTransfemoral Rehabilitation Progression: OPRAFunctional BenefitsAdditional ConsiderationsSlide Number 19